PacifiCare HMO/MCO 101 Presentation

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PacifiCare HMO/MCO 101 Presentation

• 2007

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The purpose of this PowerPoint presentation is to
provide a general overview of what you might want
to include in a presentation given to either a
new group or renewing group during enrollment
season. Please verify that the information in
the slides you choose to use is applicable to
your region. Because there are so many different
plan offerings and nuances in each market some
information may not be applicable for your
region. Please feel free to add or delete slides
and/or language as needed.
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• HMO / MCO plans
• If cost of coverage is the concern, an HMO / MCO
  may be the right choice. Care is provided
  entirely within a single HMO / MCO network, and
  the out of pocket expenses are general small.
• Members select a primary care physician from the
  health plans network of contracted providers to
  coordinate all of their care
• They see a primary care physician for covered
  services as often as they need and obtain
  referrals for specialist services
• They pay a co-payment for designated services
• Little or no paperwork or claim forms are
  required
• There are no pre-existing exclusions
• Coverage includes preventive health care, most
  immunizations and physical examinations at
  regular intervals

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Who are the Primary Care Physicians (PCP)

• Family Practice
• General Practice
• Internal Medicine
• Pediatrics

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What benefits are included in the HMO/MCO plan?

• PCP office visits at a set copay per visit
• Specialist visits at a set copay per visit
  sometimes twice the PCP copay
• Hospitalization usually paid at 100 or
  may include a copay
• Emergency at a set copay (waived if
  admitted)
• Urgent Care at a set copay
  copay usually the same as the PCP office
  visit

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What benefits are included in the PacifiCare HMO
plan cont...?

• Ambulance
  Paid at 100 or a copay may apply
• Standard Lab X-Ray a set
  copay applies per visit waived it provided
  as part of office visit
• Specialized Scanning Imaging a set copay
  applies per procedure
• Rehabilitative Therapy a
  set copay per therapy treatment
• Physical, Occupational, Speech Therapy
• Limited to a specific number of visits per year

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Prescription Medication (If applicable)

• PacifiCare Formulary
• Generic a set copay (30 day supply)
• Brand-Name Drugs a set copay copay
  (30 day supply)
• Non-Formulary Drugs Require Pre-authorization
• Mail-order prescription service available through
  Prescription Solutions just call 1-800-562-6223

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Health Improvement Programs

• Pregnancy to Preschool
• Menopause Understanding your Options
• 24 Hour Information Nurse Line
• Taking Charge of Your Heart Health
• Taking Charge of DiabetesSM
• StopSmokingSM

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PacifiCare PerksSM PacifiCare Perks services
and/or products are administered through
PacifiCare Health Plan Administrators, a
subsidiary of PacifiCare Health Systems.

• Exclusive Members-Only discount program
• Includes discounts through vendor arrangements
• Family safety products, health clubs, alternative
  care, vitamins, vision care services, natural
  body care products and much more!

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PacifiCare HealthCreditsSM

• Value-added program designed to help lower health
  care costs and increase employee productivity
• Available to all PacifiCare commercial medical
  members at no additional premium cost
• Encourages and rewards employees who actively
  participate in
• PacifiCares VirtualHealthClubSM
• Completing a Health Risk Assessment
• Health and disease management programs

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Honors Recognition

• A Fortune Global 500 Company -- PacifiCare ranked
  496 in Fortune Magazine's annual listing of the
  500 largest corporations in the world, July 26,
  2004
• Innovators Award sponsored by Health Insurance
  Association of America
• Health Financing Innovator Award from the
  Foundation for Accountability
• American Business Awards Stevie award Finalist,
  Womens Health Solutions Best New
  Product/Service
• One of the Best Places to work for Latinos,
  Hispanic Magazine
• 10 Best Companies for Asian Americans, Asian
  Enterprise Magazine
• Black Chamber of Commerce 2004 Corporation of the
  Year
• Selected by local providers for being the best
  performer among HMOs

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PHS Quality Pedigree Quality Accountability

• NCQA Accreditation
• QUALITY INDEX Profile hailed by purchasers,
  regulators, consumers, providers, CMS, NCQA, IOM,
  AHRQ
• HEDIS - Met or Exceeded Industry Average in 5
  HEDIS Effectiveness of Care Measures compared to
  California Health Plan Competitors
• Ranked 1 for Patient Satisfaction Among Network
  Model HMOs in California (Consumer Reports,
  October 2001)
• AAHPs 2001 National Exemplary Practice Award for
  Congestive Heart Failure Program (CHF) in Colorado

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PacifiCare of Arizona - Quick Facts

• NCQA Status Excellent (Commercial) and
  Commendable (MedicareChoice)
• Rated among the top-five NCQA Accredited plans in
  Arizona
• Highest rated health plan in Arizona as reported
  in NCQAs Quality Compass.
• AM Best Rating B Very Good

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PacifiCare of California Quick Facts

• NCQA Status Excellent (Commercial HMO/POS) and
  Commendable (MedicareChoice)
• Highest rated health plan in California as
  reported in NCQAs Quality Compass.
• Highest average ratings in CAHPS, cardiovascular
  health, womens health and rated second in
  category of young families.
• AM Best Rating A- Excellent

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PacifiCare of Colorado - Quick Facts

• NCQA Status Excellent (both Commercial HMO/POS
  and MedicareChoice plans)
• HEDIS and CAHPS Scores
• AM Best Rating B Very Good

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PacifiCare of Nevada - Quick Facts

• NCQA Status Commendable (both Commercial and
  MedicareChoice plans)
• Highest rated health plan in Nevada as reported
  in NCQAs Quality Compass.
• AM Best Rating B Very Good

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PacifiCare of Oklahoma Quick Facts

• NCQA Status Excellent (both Commercial and
  MedicareChoice plans)
• Rated among the top-five NCQA Accredited plans in
  Oklahoma
• AM Best Rating B Very Good

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PacifiCare of Oregon - Quick Facts

• NCQA Status Excellent (both Commercial and
  MedicareChoice plans)
• HEDIS and CAHPS Scores
• AM Best Rating B Very Good
• AHIPs National Exemplary Practice Award for the
  Taking Charge of Diabetes Program in Oregon
  Washington

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PacifiCare of Texas - Quick Facts

• NCQA Status Excellent (Commercial) and
  Commendable (MedicareChoice)
• Rated among the top-five NCQA Accredited plans in
  Texas
• AM Best Rating B Very Good

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PacifiCare of Washington - Quick Facts

• NCQA Status Excellent (both Commercial and
  MedicareChoice plans)
• HEDIS and CAHPS Scores
• AM Best Rating B Very Good
• AHIPs National Exemplary Practice Award for the
  Taking Charge of Diabetes Program in Oregon
  Washington

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Customer Service

• First Call Resolution
• Expanded hours of operation
• New Member Welcome Campaign
• IVR/ASR/CTI
• Member Satisfaction drivers

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PacifiCare Customer Service
1-800-347-8600
Available 7 a.m. - 8 p.m. Monday -
Friday Spanish Speaking Associates Also
Available
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PacifiCare on the Web

• www.pacificare.com
• HMO Provider Directory
• Formulary
• Frequently Asked Questions
• Health Improvement Programs

• PacifiCare Perks
• Contact Us area
• Online Member Publications

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How to Enroll with PacifiCareIts as Easy as
1,2,3!

• Select a PCP
• Complete your Enrollment Form
• Submit your Enrollment Form to your Employer